APPENDIX D
REQUIRED FORMS
FOR
REQUEST FOR PROPOSALS (RFP)
APPENDIX D
TABLE OF CONTENTS
REQUIRED FORMS
EXHIBITS
BUSINESS FORMS
1 PROPOSER’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
2 PROSPECTIVE CONTRACTOR REFERENCES
3 PROSPECTIVE CONTRACTOR LIST OF CONTRACTS
4 PROSPECTIVE CONTRACTOR LIST OF TERMINATED CONTRACTS
5 CERTIFICATION OF NO CONFLICT OF INTEREST
6 FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION
7 REQUEST FOR LOCAL SBE PREFERENCE PROGRAM CONSIDERATION AND
CBE FIRM/ORGANIZATION INFORMATION FORM
8 PROPOSER’S EEO CERTIFICATION
9 ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS
10 CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM CERTIFICATION FORM AND APPLICATION FOR EXCEPTION
11 CERTIFICATION OF INDEPENDENT PRICE DETERMINATION AND ACKNOWLEDGEMENT OF RFP RESTRICTIONS
2004 NONPROFIT INTEGRITY ACT (SB 1262, CHAPTER 919)
12 CHARITABLE CONTRIBUTIONS CERTIFICATION
TRANSITIONAL JOB OPPORTUNITIES PREFERENCE PROGRAM
13 TRANSITIONAL JOB OPPORTUNITIES PREFERENCE APPLICATION
DEFAULTED PROPERTY TAX REDUCTION PROGRAM
14 CERTIFICATION OF COMPLIANCE WITH THE COUNTY’S DEFAULTED PROPERTY TAX REDUCTION PROGRAM
DISABLED VETERANS BUSINESS ENTERPRISE PREFERENCE PROGRAM
15 REQUEST FOR DISABLED VETERAN BUSINESS ENTERPRISE PREFERENCE PROGRAM CONSIDERATION
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 1
PROPOSER’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT
Page 1 of 2
Please complete, date and sign this form and place it as the first page of your proposal. The person signing the form must be authorized to sign on behalf of the Proposer and to bind the applicant in a Contract.
1. If your firm is a corporation or limited liability company (LLC), state its legal name (as found in your Articles of Incorporation) and State of incorporation:
______
Name State Year Inc.
2. If your firm is a limited partnership or a sole proprietorship, state the name of the proprietor or managing partner:
______
3. If your firm is doing business under one or more DBA’s, please list all DBA’s and the County(s) of registration:
Name County of Registration Year became DBA
______
______
4. Is your firm wholly or majority owned by, or a subsidiary of, another firm? ____ If yes,
Name of parent firm: ______
State of incorporation or registration of parent firm:______
5. Please list any other names your firm has done business as within the last five (5) years.
Name Year of Name Change
______
______
6. Indicate if your firm is involved in any pending acquisition/merger, including the associated company name. If not applicable, so indicate below.
______
______
Page 2 of 2
Proposer acknowledges and certifies that it meets and will comply with Proposer’s Minimum Mandatory Qualifications as stated in Section 3.0, of this Request for Proposal.
Check the appropriate boxes:
o Yes o No _____ years experience, within the last ___ years
Proposer further acknowledges that if any false, misleading, incomplete, or deceptively unresponsive statements in connection with this proposal are made, the proposal may be rejected. The evaluation and determination in this area shall be at the Director’s sole judgment and his/her judgment shall be final.
Proposer’s Name:
______
Address:
______
______
E-mail address:______Telephone number:______
Fax number: ______
On behalf of ______(Proposer’s name), I ______
(Name of Proposer’s authorized representative), certify that the information contained in this Proposer’s Organization Questionnaire/Affidavit is true and correct to the best of my information and belief.
______
Signature Internal Revenue Service
Employer Identification Number
______
Title California Business License Number
______
Date County WebVen Number
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 2
PROSPECTIVE CONTRACTOR REFERENCES
Contractor’s Name:______
List Five (5) References where the same or similar scope of services were provided in order to meet the Minimum Requirements stated in this
solicitation.
1. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
2. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
3. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
4. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
5. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 3
PROSPECTIVE CONTRACTOR LIST OF CONTRACTS
Contractor’s Name:______
List of all public entities for which the Contractor has provided service in order to meet the Minimum Requirements stated in this
solicitation. Use additional sheets if necessary.
1. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
2. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
3. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
4. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
5. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 4
PROSPECTIVE CONTRACTOR LIST OF TERMINATED CONTRACTS
Contractor’s Name:______
List of all contracts that have been terminated within the past three (3) years.
1. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. Reason for Termination:
2. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. Reason for Termination:
3. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. Reason for Termination:
4. Name of Firm Address of Firm Contact Person Telephone # Email:
( )
Name or Contract No. Reason for Termination:
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 5
CERTIFICATION OF NO CONFLICT OF INTEREST
The Los Angeles County Code, Section 2.180.010, provides as follows:
CONTRACTS PROHIBITED
Notwithstanding any other section of this Code, the County shall not contract with, and shall reject any proposals submitted by, the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract:
1. Employees of the County or of public agencies for which the Board of Supervisors is the governing body;
2. Profit-making firms or businesses in which employees described in number 1 serve as officers, principals, partners, or major shareholders;
3. Persons who, within the immediately preceding 12 months, came within the provisions of number 1, and who:
a. Were employed in positions of substantial responsibility in the area of service to be performed by the contract; or
b. Participated in any way in developing the contract or its service specifications; and
4. Profit-making firms or businesses in which the former employees, described in number 3, serve as officers, principals, partners, or major shareholders.
Contracts submitted to the Board of Supervisors for approval or ratification shall be accompanied by an assurance by the submitting department, district or agency that the provisions of this section have not been violated.
______
Proposer Name
______
Proposer Official Title
______
Official’s Signature
REQUIRED FORMS - EXHIBIT 6
FAMILIARITY WITH THE COUNTY
LOBBYIST ORDINANCE CERTIFICATION
The Proposer certifies that:
1) it is familiar with the terms of the County of Los Angeles Lobbyist Ordinance, Los Angeles Code Chapter 2.160;
2) that all persons acting on behalf of the Proposer organization have and will comply with it during the proposal process; and
3) it is not on the County’s Executive Office’s List of Terminated Registered Lobbyists.
Signature:______Date:______
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 7
Request for Local SBE Preference Program Consideration andCBE Firm/Organization Information Form
INSTRUCTIONS: All proposers/bidders responding to this solicitation must complete and return this form for proper consideration of the proposal/bid.
I. LOCAL SMALL BUSINESS ENTERPRISE PREFERENCE PROGRAM:
FIRM NAME: ______CAGE CODE:______NAICS CODE:______
q As a business registered as ‘Small’ on the federal Central Contractor Registration (CCR) data base, I request this proposal/bid be considered for the Local SBE Preference.
q The NAICS Code shown corresponds to the services in this solicitation.
q Attached is my CCR certification page.
My County (WebVen) Vendor Number :______
______
II. FIRM/ORGANIZATION INFORMATION: The information requested below is for statistical purposes only. On final analysis and consideration of award, contractor/vendor will be selected without regard to race/ethnicity, color, religion, sex, national origin, age, sexual orientation or disability.
Business Structure: q Sole Proprietorship q Partnership q Corporation q Non-Profit q Franchiseq Other (Please Specify) ______
Total Number of Employees (including owners):
Race/Ethnic Composition of Firm. Please distribute the above total number of individuals into the following categories:
Race/Ethnic Composition / Owners/Partners/
Associate Partners / Managers / Staff
Male / Female / Male / Female / Male / Female
Black/African American
Hispanic/Latino
Asian or Pacific Islander
American Indian
Filipino
White
III. PERCENTAGE OF OWNERSHIP IN FIRM: Please indicate by percentage (%) how ownership of the firm is distributed.
Black/African American / Hispanic/ Latino / Asian or Pacific Islander / American Indian / Filipino / WhiteMen / % / % / % / % / % / %
Women / % / % / % / % / % / %
IV. CERTIFICATION AS MINORITY, WOMEN, DISADVANTAGED, AND DISABLED VETERAN BUSINESS ENTERPRISES: If your firm is currently certified as a minority, women, disadvantaged or disabled veteran owned business enterprise by a public agency, complete the following and attach a copy of your proof of certification. (Use back of form, if necessary.)
Agency Name / Minority / Women / Dis-advantaged / Disabled Veteran / Expiration DateIV. DECLARATION: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.
Print Authorized Name / Authorized Signature / Title / DateRFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 8
PROPOSER’S EEO CERTIFICATION
______
Company Name
______
Address
______
Internal Revenue Service Employer Identification Number
GENERAL
In accordance with provisions of the County Code of the County of Los Angeles, the Proposer certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America and the State of California.
CERTIFICATION YES NO
1. Proposer has written policy statement prohibiting
discrimination in all phases of employment. ( ) ( )
2. Proposer periodically conducts a self-analysis or
utilization analysis of its work force. ( ) ( )
3. Proposer has a system for determining if its employment
practices are discriminatory against protected groups. ( ) ( )
4. When problem areas are identified in employment practices,
Proposer has a system for taking reasonable corrective
action to include establishment of goal and/or timetables. ( ) ( )
______
Signature Date
______
Name and Title of Signer (please print)
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 9
ATTESTATION OF WILLINGNESS TO CONSIDER
GAIN/GROW PARTICIPANTS
As a threshold requirement for consideration for contract award, Proposer shall demonstrate a proven record for hiring GAIN/GROW participants or shall attest to a willingness to consider GAIN/GROW participants for any future employment opening if they meet the minimum qualifications for that opening. Additionally, Proposer shall attest to a willingness to provide employed GAIN/GROW participants access to the Proposer’s employee mentoring program, if available, to assist these individuals in obtaining permanent employment and/or promotional opportunities.
To report all job openings with job requirements to obtain qualified GAIN/GROW participants as potential employment candidates, Contractor shall email: .
Proposers unable to meet this requirement shall not be considered for contract award.
Proposer shall complete all of the following information, sign where indicated below, and return this form with their proposal.
A. Proposer has a proven record of hiring GAIN/GROW participants.
______YES (subject to verification by County) ______NO
B. Proposer is willing to provide DPSS with all job openings and job requirements to consider GAIN/GROW participants for any future employment openings if the GAIN/GROW participant meets the minimum qualifications for the opening. “Consider” means that Proposer is willing to interview qualified GAIN/GROW participants.
______YES ______NO
C. Proposer is willing to provide employed GAIN/GROW participants access to its employee-mentoring program, if available.
______YES ______NO ______N/A (Program not available)
Proposer’s Organization: ______
Signature: ______
Print Name: ______
Title: ______Date: ______
Telephone No: ______Fax No: ______
RFP - APPENDIX D – Required Forms
Rev. 12/15/15
REQUIRED FORMS - EXHIBIT 10
COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM
CERTIFICATION FORM AND APPLICATION FOR EXCEPTION
The County’s solicitation for this Request for Proposals is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program), Los Angeles County Code, Chapter 2.203. All proposers, whether a contractor or subcontractor, must complete this form to either certify compliance or request an exception from the Program requirements. Upon review of the submitted form, the County department will determine, in its sole discretion, whether the proposer is given an exemption from the Program.